Anxiety Disorders

Question 1

What drugs may cause drug-induced anxiety?

Answer 1

Salbutamol
Theophylline
Corticosteroids
Antidepressants
Caffeine

Question 2

Stepwise management of GAD?

Answer 2

step 1: education about GAD + active monitoring

step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)

step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.

step 4: highly specialist input e.g. Multi agency teams

Question 3

Pharmacological management of GAD?

Answer 3

NICE suggest sertraline should be considered the first-line SSRI

if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (duloxetine, venlafaxine)

If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin

Busipirone (5HT1A¬ agonist) is suitable for short term management
Delayed onset of action
Diminished efficacy in previous benzo users
Side effects: dizziness, headache and nausea
Minimal sedation

Beta blockers such as propranolol can be used for somatic symptoms

Low dose antipsychotics can be considered

Question 4

Management of panic disorder?

Answer 4

NICE recommend either cognitive behavioural therapy or drug treatment

SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 5

What is OCD, and what is meant by obsessions and compulsions?

Answer 5

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.

Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

Question 6

Possible aetiological factors for OCD?

Answer 6

genetic
psychological trauma
pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)

Question 7

What other psychiatric conditions are associated with OCD?

Answer 7

depression (30%)
schizophrenia (3%)
Sydenham’s chorea
Tourette’s syndrome
anorexia nervosa

Question 8

How is OCD managed if functional impairment is low?

Answer 8

low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)

If this is insufficient or can’t engage in psychological therapy, then offer choice of either a course of an SSRI or more intensive CBT (including ERP)

Question 9

How is OCD managed if functional impairment is moderate?

Answer 9

offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)

Question 10

How is OCD managed if functional impairment is severe?

Answer 10

offer combined treatment with an SSRI and CBT (including ERP)

Question 11

What is post traumatic stress disorder?

Answer 11

Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse.

One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month.

Question 12

Features of PTSD?

Answer 12

re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images

avoidance: avoiding people, situations or circumstances resembling or associated with the event

hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating

emotional numbing - lack of ability to experience feelings, feeling detached from other people
depression

drug or alcohol misuse

anger

unexplained physical symptoms

Question 13

Management of PTSD?

Answer 13

following a traumatic event single-session interventions (often referred to as debriefing) are not recommended

watchful waiting may be used for mild symptoms lasting less than 4 weeks

military personnel have access to treatment provided by the armed forces

trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases

drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used

Question 14

Examples of anxiety disorders?

Answer 14

Generalized Anxiety disorder
Phobias
Panic disorder
Obsessive Compulsive Disorder Post-traumatic Stress Disorder

Question 15

Concept of neuroses

Answer 15

Symptoms that are both understandable and with which one can empathize

Insight is maintained - this is as opposed to delusions which are not understandable or cannot be empathised with

Neuroses are quantitively but not qualitatively different from normal

Neuroses different to ‘neurotic’ individuals who often suffer from lifelong personality difficulties

Question 16

Social factors associated with anxiety disorders?

Answer 16

Lower social class
Unemployment
Divorced
Renting rather than owning
No educational qualifications
Urban living Aetiology

Question 17

In which patients are anxiety disorders more common?

Answer 17

Females
Younger patients (from 35-40 years and older dx more likely to be depression or an organic pathology)

Question 18

Psychological symptoms of anxiety?

Answer 18

Fears
Worries
Poor concentration
Irritability
Depersonalization
Derealisation
Insomnia
Night terrors

Question 19

Motor symptoms of anxiety?

Answer 19

Restlessness
Fidgeting
Feeling on edge

Question 20

Neuromuscular symptoms of anxiety?

Answer 20

tremor
tension headache
muscle ache
dizziness
tinnitus

Question 21

GI symptoms of anxiety

Answer 21

Dry mouth
Trouble swallowing
Nausea
Indigestion
Flatulence
Frequent or loose motions

Question 22

What ?CVS symptoms might anxiety present with

Answer 22

Chest discomfort, palpitation

Question 23

What respiratory complaints might anxiety present with

Answer 23

Difficulty inhaling, Tight/constricted chest

Question 24

What GU symptoms might anxiety present with?

Answer 24

Urinary frequency
Erectile dysfunction
Amenorrhoea

Question 25

ICD-10 criteria for GAD

Answer 25

Generalized and persistent 'free floating' anxiety symptoms involving elements of: Apprehension (worries about future misfortunes, feeling on edge, difficulty in concentrating) Motor tension (restless fidgeting, tension headaches, trembling, inability to relax) Autonomic overactivity (light-headedness, sweating, tachycardia, epigastric discomfort, dizziness etc)

Question 26

Differential diagnoses for GAD?

Answer 26

Hyperthyroidism (look for goitre, tremor, tachycardia, weight loss, arrhythmia, exophthalmos) Substance misuse (intoxication – amphetamines; withdrawal – benzo, alcohol) Excess caffeine Depression: anxiety common feature of depression and likewise. Which came first and which is currently more prominent are useful clues. If both, diagnose mixed anxiety and depressive disorder Anxious (avoidant) personality disorder: patient describes themselves as an anxious person with no recent major increase in anxiety levels. (note this disorder can predispose) Dementia (early) Schizophrenia (early)

Question 27

ICD-10 criteria for panic disorder?

Answer 27

Recurrent attacks of severe anxiety not restricted to any particular situation or set of circumstances and therefore unpredictable Secondary fears of dying, losing control or going mad Attacks usually last for minutes; often there is a crescendo of fear and autonomic symptoms Comparative freedom from anxiety symptoms between attacks (but anticipatory anxiety is common)

Question 28

Which patients are most greatly affected by panic disorders?

Answer 28

2-3x more common in females Bimodal: peaks at 20yo and 50yo

Question 29

What increases the risk of suicide in anxiety disorders?

Answer 29

comorbid depression, alcohol misuse or substance misuse

Question 30

Concurrent agrophobia is common in which anxiety disorder?

Answer 30

Painic disorder

Question 31

iClinical features of panic disorder?

Answer 31

Breathing difficulties Chest discomfort Palpitations Tingling or numbness in hands, feet or around the mouth: Hyperventilation blows off CO2, raising pH, Calcium binds to albumin leads to hypocalcaemia. If extreme, carpopedal spasm (curling of fingers and toes can occur) Shaking, sweating, dizziness Depersonalization/ derealisation Can lead to fear of situation where panic attacks occur or agoraphobia Conditioned fear of fear pattern develops

Question 32

Differential diagnoses of panic disorder?

Answer 32

Other anxiety disorders: GAD and agoraphobia Depression (if depression precedes or criteria for depression fulfilled, it takes precedence) Alcohol or drug withdrawal Organic causes: CVS or respiratory disease. Others: hypoglycaemia, hyperthyroidism. Rarely: pheochromocytoma.

Question 33

Physiological management of panic disorder?

Answer 33

Reassurance CBT effective in 80-100% CBT is first line Initial education about nature of panic attacks and fear of fear cycles Cognitive restructuring; detecting flaws in logic Interoceptive exposure techniques such as controlled exposure to somatic symptoms(breathing in CO2 and physical exercise) Secondary agoraphobic avoidance: treat by situational exposure and anxiety management techniques

Question 34

Drug management of panic disorder?

Answer 34

SSRIs are first line drug treatment (but 2nd line to CBT) Also, clomipramine (tricyclic with similar action on serotonin) is effective Prognosis 50-60% remit with medication; 80-100% with CBT

Question 35

Features of mixed anxiety and depressive disorder?

Answer 35

ICD-10 criteria: symptoms of anxiety and depression are both present but neither clearly predominates Treat with counselling, cognitive therapy or psychotherapy, especially interpersonal therapy Treating the depression usually relieves anxiety symptoms (SSRIs are best)

Question 36

Features of specific/isolated phobias?

Answer 36

ICD-10 criteria: restricted to highly specific situations such as proximity to particular animals, heights, thunder, flying, blood etc Often clear in early adulthood Result in avoidance Phobias of blood and bodily injury lead to bradycardia and hypotension upon exposure Severity depends on effect on quality of life ( pilots afraid of flying) Always exclude co-morbid depression

Question 37

Features of agoraphobia?

Answer 37

ICD-10 criteria: Fear not only open spaces but also of related aspects, such as the presence of crowds and difficulty of immediate easy escape back to a safe place, usually home (may occur with or without panic disorder) Commonly in 20s or mid-thirties May be gradual or precipitated by a sudden panic attack Comorbid depression is common (be wary of drugs and alcohol to overcome) Also higher incidence of sexual problems

Question 38

Agoraphobia differentials

Answer 38

Depression Social phobia Obsessive Compulsive Disorder Schizophrenia (may stay because of social withdrawal or as a way of avoiding perceived persecutors)

Question 39

Features of social phobias

Answer 39

Most common anxiety disorder ICD-10 criteria: Fear of scrutiny by other people in comparatively small groups (as opposed to crowds), leading to avoidance of social situations Comparatively small = around 5-6 people (Usually 1-2 is fine) May be specific (public speaking) or generalized (any social setting) Physical symptoms: blushing, fear of vomiting Symptoms include blushing (characteristic), palpitations, trembling, sweating Can be precipitated by stressful or humiliating experiences, death of a parent, separation, chronic stress Genetic vulnerability May abuse alcohol or drugs (perpetuating problem) Mental state examination: may appear relaxed as phobic object or situation not present

Question 40

Differentials for phobias

Answer 40

Shyness (in social phobia, there is fear) Agoraphobia Anxious personality disorder Poor social skills/autistic spectrum disorders (will not show good skills when relaxed) Benign essential tremor (familial, worse in social situations, responds to benzo and alcohol)

Question 41

Investigation of ?phobia

Answer 41

History and Examination Rating scales of anxiety: Beck Anxiety Inventory and the HADs score (Hospital anxiety and Depression scale) Social and occupational assessments for effect on quality of life Collateral History

Question 42

Which phobias have the best outcome

Answer 42

Animal phobias

Question 43

Which phobias have the worst outcome?

Answer 43

Agoraphobias

Question 44

Management of phobias

Answer 44

Flooding (taking someone with fear of heights to a tower) Modelling (individual observes therapist engaging with phobic stimulus) Agoraphobia and panic disorders: CBT treatment of choice Social phobia: CBT is the treatment of choice Drug management SSRIs and MAOIs (phenelzine) most useful in agoraphobia and social phobia Tricyclic antidepressants best for those with depressive component Agoraphobia + panic disorder: CBT first line and SSRI 2nd line Benzodiazepines can be used before a phobic situation B-blockers are effective if somatic symptoms predominate

Question 45

What can be used to help establish the sevrity of GAD diagnosis

Answer 45

The GAD-7 anxiety questionnaire can help establish the severity of the diagnosis

Question 46

Enviromental triggers/contributers for GAD

Answer 46

Family relationships Friendships Bullies/abuse Work or school pressures Alcohol and drug use

Question 47

The cycle of behaviours in OCD

Answer 47

The obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary improvement in the anxiety. Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief. This cycle continues and each time gets more engrained in the person’s behaviour. Without doing the compulsions, the person feels they cannot get relief from their anxiety. The obsessions and compulsions are present on a daily basis and are not something the person will enjoy or do willingly. They impact on other areas of life, such as their social life or other interests.

Question 48

What is meant by the term 'anxiety'

Answer 48

Anxiety can be defined as a constellation of psychological and physiological responses to a potential/uncertain threat and is an essential function of the central nervous system (CNS). It is analogous to pain in that it is an unpleasant experience which exists to automatically motivate us to avoid harm.

Question 49

What is 'trait anxiety'?

Answer 49

“Trait anxiety” is your propensity to experience the anxiety response when exposed to a stressor. It is a stable characteristic arising from a multitude of genetic and environmental factors, particularly adaptive responses to experiences of potential threat during development (for instance bullying, trauma, neglect or parental loss), as well as the nature of early attachment relationships. These experiences ‘calibrate’ the CNS response to a threat in adulthood. As you would expect, high trait anxiety confers a greater survival advantage

Question 50

State anxiety vs trait anxiety

Answer 50

“State anxiety” is simply the state of feeling anxious, as opposed to 'trait anxiety' which is the propensity to experience anxiety when exposed to a stressor

Question 51

Clinical signs that may be present in anxiety?

Answer 51

tachycardia, tachypnoea, tremor, sweating, pallor, pupil dilation

Question 52

What is rumination?

Answer 52

Rumination (continuously thinking about the same thing) occurs in various psychiatric disorders, and the process of recurrently thinking through possible catastrophic outcomes of one’s situation (also known as worrying) is another function of state anxiety which we can assume was useful in evolutionary terms; it is thought to represent an automatic attempt at problem-solving, which serves to maintain a state of vigilance for potential danger. However, in the context of anxiety disorders, it may further increase state anxiety.

Question 53

What are the neurophysiological changes underpinning anxiety?

Answer 53

Reduced functional connectivity between the prefrontal cortex and the limbic system (especially the amygdala and anterior cingulate cortex): these connections are thought to subserve conscious control/awareness of emotional states. Single nucleotide polymorphism variations in 5-HT (serotonin) transporter, resulting in diminished 5-HT signalling: this is the basis of the “Monoamine Hypothesis” of anxiety and depression and is the target of the most widely used antidepressants, the selective serotonin reuptake inhibitors. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis: this is the term used to describe the self-regulating neuronal and hormonal interaction between the hypothalamus, the pituitary gland and the adrenal glands, which is a central component of the physiological response to stress (see here for more information).

Question 54

To meet the criteria for any anxiety order, what features of symptoms must be present?

Answer 54

Persist for several months, on more days than not Result in significant impairment (in personal, family, social, educational, occupational, or other important areas of functioning) Not be a manifestation of another health condition or the effects of a substance/medication

Question 55

Common features of GAD?

Answer 55

Subjective experience of nervousness Difficulty maintaining concentration Muscular tension or motor restlessness Sympathetic autonomic over-activity Irritability Sleep disturbance.

Question 56

Common features of phobic anxiety disoders

Answer 56

Anticipatory anxiety (about exposure to precipitant, and about anxiety itself) Somatic symptoms (e.g. palpitations, sweating, trembling, dyspnoea, chest pain, dizziness, chills, hot flushes)

Question 57

Characteristic features of anxiety disorders?

Answer 57

A crescendo of anxiety, usually resulting in exit from the situation Somatic symptoms (e.g. palpitations, sweating, trembling, dyspnoea, chest pain, dizziness, chills, hot flushes) Secondary fear of dying/losing control (often related to the somatic symptoms)

Question 58

Stepwise general treatment of anxiety disoders?

Answer 58

Psychoeducation, sleep hygiene, and self-guided cognitive-based therapy (CBT)/ relaxation techniques: it may be helpful to acknowledge that these can appear basic/low intensity, but emphasise their evidenced effectiveness for mild/moderate anxiety if done regularly. CBT: identifying then gradually unlearning the maladaptive patterns of thought/behaviour which are perpetuating symptoms. A CBT practitioner may employ techniques such as exposure therapy (allows extinction of erroneously learned fears) and applied relaxation. Pharmacological (equal 1st line with CBT). SSRI (e.g. escitalopram or sertraline), SNRI (e.g. duloxetine or venlafaxine) or atypical antidepressant (e.g. Mirtazapine) with the choice depending on side-effect profile.

Question 59

When might benzodiazepines be suitable to manage anxiety disorders?

Answer 59

They can be used for transient causes of anxiety (ie. fear of flying) or in crisis only, maximum of 2 weeks prescription advised.

Question 60

HARD - charecteristic features of PTSD?

Answer 60

Hyperarousal: persistently heightened perception of current threat (may include enhanced startle reaction) Avoidance of situations/activities reminiscent of the events, or of thoughts/memories of the events Re-experiencing the traumatic events (vivid intrusive memories, flashbacks, or nightmares). Distress: strong/overwhelming fear and physical sensations when re-experiencing

Question 61

What is C-PTSD

Answer 61

C-PTSD is a disorder that may develop following exposure to series of extremely threatening/horrific events, commonly prolonged or repetitive situations from which escape is difficult (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). C-PTSD can be thought of as a constellation of significant modifications to a person’s automatic threat response, occurring because of having to adapt to prolonged/repetitive trauma.

Question 62

Criteria for C-PTSD?

Answer 62

Characteristic features of C-PTSD include all diagnostic requirements for PTSD (above), plus: Severe and persistent problems in affect regulation Severe and persistent low self-worth, accompanied by feelings of shame/guilt/failure related to the traumatic events Severe and persistent difficulties in sustaining relationships and in feeling close to others.

Question 63

Obsessive-compulsive or related disorders are a group of disorders characterised by repetitive thoughts and behaviours, including what?

Answer 63

Obsessive-compulsive disorder (OCD) Body dysmorphic disorder (BDD) Body-focused repetitive behaviour disorders (ie. trichotillomania, dermatillomania) Hypochondriasis (health anxiety disorder) Hoarding disorder

Question 64

What is acute distress disorder and how does it differ from PTSD?

Answer 64

Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc). This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.

Question 65

Features of acute stress disorder

Answer 65

intrusive thoughts e.g. flashbacks, nightmares dissociation e.g. 'being in a daze', time slowing negative mood avoidance arousal e.g. hypervigilance, sleep disturbance

Question 66

Management of acute stress disorder

Answer 66

trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line benzodiazepines - sometimes used for acute symptoms e.g. agitation, sleep disturbance - should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation

Question 67

Acute stress reaction vs adjustment disorder?

Answer 67

The key difference between these conditions is that an acute stress reaction will typically follow a highly stressful event, whereas with adjustment disorder, the stressor need not be severe or outside the "normal" human experience. For example, the difference between seeing a fatal car accident vs being made redundant.

Question 68

What is adjustment disorder?

Answer 68

A state of emotional distress and disturbance usually interfering with social functioning arising in a period of adaptation to a significant life change or stressful life event such as bereavement or separation

Question 69

What is the definition of a neurotic disorder?

Answer 69

Neurosis refers to a class of functional mental disorder involving distress but not delusions or hallucinations, where behavior is not outside socially acceptable norms

Question 70

When does autonomic response cause anxiety disorders

Answer 70

Symptoms and pathological response/arousal remain increased disproportionate to the treat

Question 71

Phobias

Answer 71

Anxiety in particular cirumstances, leading to avoidance Anticipatory anxiety, cannot be reasoned away Crowds, living things, natural phenomena Self help, medication, CBT

Question 72

Common triggers for agoraphobia

Answer 72

Distance from home Crowding Open space Social situations

Question 73

Peak of onset of agoraphobia?

Answer 73

20s and 30s

Question 74

SSRIs - advantages

Answer 74

SSRIs are widely used due to their relatively little effect on other neurotransmitters including dopamine, noradrenaline, histamine, and acetylcholine. This limits the side-effect profile and improves concordance.

Question 75

Which anxiety disorder is not more common in women?

Answer 75

Social phobias - gender mix

Question 76

What is a social phobia commonly associated with

Answer 76

Substance misuse

Question 77

Phobia vs panic disorders?

Answer 77

Phobia - trigger, symptoms only related to specific trigger Panic - no trigger

Question 78

According to NICE, if a person presents in A&E with a panic attack, they should:

Answer 78

be asked if they are already receiving treatment for panic disorder undergo the minimum investigations required to exclude acute physical problems not usually be admitted to a medical or psychiatric ward be reffered to primary care for subsequent management even if assesment has been undertaken in a and e be offered appropriate written information about sources of support, including local and national voluntary self-help groups

Question 79

What are Egodystonic thoughts

Answer 79

Unpleasent/distressing thoughts

Question 80

Thoughts in OCD

Answer 80

Thoughts - reccurent ideas, images, impulsion Distressing Patient tries to resist, recognises thoughts as their own --- insight

Question 81

OCD pathophysiology

Answer 81

Cortical-subcortical re-entrant circuits and recurrent behaviour Recurrent symptoms occur as a result of incoordination between phasic subcortical inputs and synaptic gating processes in cortical-subcortical circuits. Excess arousal

Question 82

Which part of the brain is responsible for the flight of fight response

Answer 82

The amygdala

Question 83

GAD risk and protective factors?

Answer 83

Risk factors for the development of GAD include; Aged 35- 54 Being divorced or separated Living alone Being a lone parent Protective factors include; Aged 16 - 24 Being married or cohabiting

Question 84

What is a diphasic response

Answer 84

Vaso-vagal syncope caused by an overcompensating rebound parasympathetic activation following sympathetic arousal Most anxiety responses involve sysmpathetic drive , with an increase in heart rate, etc. that is not going to lead to fainting (syncope). Blood-injury phobia is the classical exception an syncope (vaso-vagally mediated) can occur due to a biphasic response. (NOTE: not everyone with blood-injury phobia faints)

Question 85

Psychological therapy for PTSD

Answer 85

“Consider EMDR for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a non-combat-related trauma if the person has a preference for EMDR. Offer EMDR to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a non-combat-related trauma.”

Question 86

Cognitive theory suggests what as the most significant underlying factor in anxiety disorders?

Answer 86

Catastrophic misinterpretation (usually of somatic symptoms) is the key component in panic disorder (and is vital to explain the mechanism of panic). In other anxiety problems patients tend to have a higher perception of threat and of an adverse outcome (i.e. they forsee the worst happening in the future)